clinical cases

Case 1: A 55 year-old male with a history of hypertension and hyperlipidemia complains of fatigue, headache, shortness of breath, and blurry vision for the past four days. His exam is normal, but laboratory results show a WBC of 155,000, with differential showing elevated blasts. Chest Xray shows the following:

Case 1: A 73 year-old male presents with several weeks of cough, facial swelling, and shortness of breath. He has a history of lung cancer, actively being treated with radiation and chemotherapy. On exam, his vital signs are normal, but he has swelling of the face with a violaceous hue and elevated JVD.

Case 2: A 22 year-old female with a history of B cell lymphoma presents with nausea, vomiting, fatigue, decreased urine output, and palpitations. She has not been attending her normally scheduled cancer treatments. She is tachycardic in the 110s, and the rest of the exam is normal. Laboratory results reveal elevated phosphorus, potassium, and uric acid, with decreased calcium.

These two patients present with an emergency related to malignancy. How should you manage these patients, and what are your next steps?

A 42 year-old female with poorly controlled type II diabetes presents with several days of fatigue, headache, fever to 102F, and sinus pressure. She does not regularly check her blood glucose, with her last check at 320. Initial vital signs show a blood pressure of 155/92, heart rate of 92, oxygen saturation of 97% on room air, temperature of 102.2, and respiratory rate of 24. Initial D-stick is 330. You order some labs, which reveal an anion gap of 22, bicarbonate of 11, with glucose of 322 and potassium of 4.2. Your ECG obtained is normal. You begin your standard treatment for diabetic ketoacidosis. As you begin to go through your algorithm for management/treatment of DKA, you question why the patient is in DKA. You remember that she has had several days of headache, fever, and sinus pressure. You go back into the room after the 1L bolus to complete your exam, and what you see on your exam surprises you:

It’s a crazy night in the ED, and you are about four hours into your shift. You have just received a new patient with chief complaint of altered mental status coming in via EMS.

In the febrile HIV patient, there are many diagnostic dilemmas and potential life-threatening disease processes which make the diagnosis and treatment difficult. When approaching these patients, it is useful to separate complications into organ systems and then try to estimate the patient’s immune status if it is not known.